Accuracy of the pedal acceleration time to diagnose limb ischemia in patients with and without diabetes using the WIfI classification.

INTRODUCTION: Evaluation of limb hemodynamics using the ankle-brachial index (ABI) may be difficult due to skin lesions, extensive necrosis, and obesity, such as commonly present in patients with diabetes with chronic limb-threatening ischemia (CLTI). We hypothesized that the pedal acceleration time (PAT) correlates with ABI and Wound, Ischemia, and foot Infection (WIfI) scores in patients with diabetes to serve as a new modality to accurately stage CLTI. METHODS: A single-center, cross-sectional study included patients with and without diabetes > 18 years with CLTI. Limbs were categorized in three grades of ischemia based on the ABI (ABI < 0.8, < 0.6, and < 0.4) and in two classes based on WIfI stages of amputation risk. Receiver operator characteristic (ROC) curves were used to determine PAT sensitivity, specificity, and accuracy to predict lower-limb ischemia. RESULTS: A total of 141 patients (67 nondiabetic and 74 diabetic) and 198 lower limbs (94 nondiabetic and 104 diabetic) met the inclusion criteria. In patients without diabetes, the accuracy of PAT for detecting an ABI < 0.8 was 85%; for detecting an ABI < 0.6 was 85%; and for detecting an ABI < 0.4 was 87%. In patients with diabetes, the accuracy of PAT in detecting an ABI < 0.8 was 91%; for detecting an ABI < 0.6 was 79%; and for detecting an ABI < 0.4 was 88%. In patients without diabetes, the accuracy for detecting WIfI stages of moderate and high amputation risk was 77% and for patients with diabetes was also 77%. CONCLUSIONS: PAT shows high correlation with the ABI as well as with the WIfI stages of amputation risk and the grades of ischemia, with high accuracy.

Sclerotherapy Improves Symptoms in Patients with Small and Moderate Diameter Low-Flow Vascular Malformations: A Prospective Cohort Study.

BACKGROUND: Vascular malformations are rare diseases and treatment remains controversial. Sclerotherapy is accepted as a minimally invasive treatment with good results; however, some patients do not report good response to sclerotherapy, and it is not clear which variables influence treatment outcome, preventing optimal patient selection. We hypothesized that large diameter lesions have reduced efficacy and satisfaction with sclerotherapy. Therefore, we prospectively evaluated the clinical response of low-flow vascular malformations treated with 1% polidocanol foam sclerotherapy and determined the correlation of symptom improvement with clinical variables. METHODS: Prospective cohort study of patients with symptomatic low flow vascular malformations treated at the Hospital das Clínicas between December 2016 and November 2018. Lesions were classified according to location, extension, diameter, type of vessels, margins, and symptoms. Sclerotherapy was performed by direct injection of 1% polidocanol foam, with a maximum volume of 10 ml per session. Symptom improvement was evaluated using the visual analog scale and patient-reported quality of life was assessed by the Short-form 6 dimensions (SF-6D) questionnaire. Follow-up was performed every 3 months after treatment. RESULTS: Forty lesions were treated in 38 patients, with 19 women and 19 men; median age was 20.5 years (range 4 months to 63 years). Most lesions (80%) were venous, and most commonly in the lower limbs (47.5%); 27.5% were superficial, 35% were deep, and 37.5% affected both compartments. The most common clinical presentations were deformity (95%), pain (78%), and functional limitation (58%); deep compartment lesions were more associated with functional limitation (69% vs. 27%; P = 0.030). Fifty-three per cent of lesions were >10 cm and were associated with increased numbers of psychosocial symptoms (P = 0.038). Two-hundred and forty-two sessions of sclerotherapy were performed, with 6 mean treatments per lesion (range 1-15). The mean follow-up time was 23 months (range 2-23 months). The most common complications were pain and local edema, without any major complications; some patients reported symptom recurrence (15% pain, 10% deformity, and 12% functional limitation). Sclerotherapy was associated with significant improvement of all symptoms (P < 0.001). However, lesions >10 cm were associated with poor improvement in deformity (P = 0.003). Quality of life improved for most patients (60%) and treatment satisfaction was high (82%). CONCLUSIONS: Treatment of low-flow vascular malformations with 1% polidocanol foam is safe and effective; sclerotherapy improves symptoms and quality of life. Large diameter lesions (>10 cm) are associated with increased treatment failure. A small percentage of patients reported recurrent symptoms and require other modalities for successful treatment.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery.

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

A doença renal crônica é um problema de saúde pública global e em seu estágio terminal está associada à necessidade de terapia dialítica. A grande maioria dos pacientes que necessitam realizar a terapia renal substitutiva, a fazem através da hemodiálise. Portanto, o acesso vascular é de extrema importância para a população dialítica, implicando diretamente na qualidade de vida e na morbimortalidade deste grupo de pacientes. Sendo a confecção, gerenciamento e resgate dos acessos vasculares uma das áreas de atuação do cirurgião vascular, é de grande importância a elaboração de uma diretriz que oriente o especialista no manejo mais adequado do acesso vascular para hemodiálise. Assim, o objetivo desta diretriz é apresentar um conjunto de recomendações para guiar as decisões na referenciação, avaliação, escolha, vigilância e gestão das complicações do acesso vascular para hemodiálise.

Intraoperative vascular Doppler ultrasound blood flow and peak systolic velocity predict early patency in hemodialysis arteriovenous fistula.

BACKGROUND: Chronic kidney disease is a major public health problem. Hemodialysis is the most common renal replacement therapy. Arteriovenous fistulas (AVF) are a possible access option, but early failure rates remain high. OBJECTIVES: to investigate the value of intraoperative vascular Doppler ultrasound for predicting early AVF patency. METHODS: Prospective observational study. Consecutive patients undergoing AVF were assessed with vascular Doppler ultrasonography intraoperatively and on days 1, 7, 30, and 60. Patients were divided into groups according to presence or absence of primary and secondary patency. Blood flow (BF) and peak systolic velocity (PSV) were compared. ROC curves were plotted and used to define the PSV and BF values that yielded greatest sensitivity (Sens) and specificity (Spec). RESULTS: 47 patients met the inclusion criteria and were analyzed. Higher intraoperative PSV and BF values were observed in patients who had primary and secondary patency than in patients with access failure. The values with greatest sensitivity and specificity for predicting 30-day primary patency were 106 cm/s for venous PSV (Sens: 75% and Spec: 71.4%) and 290.5 ml/min for arterial blood flow (Sens: 80.6% and Spec 85.7%). Values for 30-day secondary patency were 106 cm/s for arterial PSV (Sens: 72.7%, Spec: 100%) and 230 ml/min for venous blood flow (Sens: 86.4%, Spec100%). Values for 60-day primary patency were 106 cm/s for venous PSV (Sens: 74.4%, Spec: 62.5%) and 290.5 ml/min for arterial blood flow (Sens: 80%, Spec: 75%). CONCLUSIONS: Peak systolic velocity and blood flow measured using intraoperative vascular Doppler ultrasound can predict early patency of hemodialysis arteriovenous fistulas.

Brachial vein transposition: an alternative to hemodialysis arteriovenous graft.

BACKGROUND: There is currently a worldwide effort to increase the options for autogenous hemodialysis access. OBJECTIVES: To evaluate patency and complications of brachial vein transposition compared to other autogenous hemodialysis accesses. METHODS: A retrospective evaluation of 43 patients and 45 procedures. Patients who did not have adequate superficial veins according to duplex scanning were allocated to brachial vein transposition. The sample was thus divided in two groups, as follows: A: brachial vein transposition n=10 and B: other autogenous accesses n=35. RESULTS: There were no statistical differences between the two groups in terms of age diabetes, systemic arterial hypertension, dyslipidemias, arteriopathies, neoplasms, kidney disease stage, donor artery diameter, recipient vein diameter, systolic blood pressure in the operated limb, postoperative ischemia, hematoma, or infection. There were no statistical differences in terms of patency on day 7: A 80% vs. B 90% p=0.6, on day 30: A 80% vs. B 86% p=0.6, or on day 60: A 60% vs. B 80% p=0.22. There were statistical differences between the groups for number of previous fistulae A 1.0 ± 0.44 vs. B 0.6 ± 0.3 p = 0.04 and upper limb edema A: 20% x B 0% p = 0.04. A vein with diameter of less than 3 mm was associated with an increased risk of early occlusion (RR = 8 p = 0.0125). During the study period there were no procedures using grafts. CONCLUSIONS: Transposition of brachial vein is an alternative to arteriovenous graft.

Risk factors for mortality among patients undergoing major amputations due to infected diabetic feet.

BACKGROUND: Foot ulcers in patients with diabetes are a major public health problem and are often associated with lower limbs amputation and mortality in this population. OBJECTIVES: To investigate the risk factors associated with mortality in patients with infected diabetic foot ulcers and major lower limb amputations. METHODS: This was an observational, retrospective, case-control study with a sample of 78 patients with infected diabetic foot ulcers who had major lower limb amputations at a Vascular Surgery Service at a university hospital. RESULTS: The mean age of the study sample was 63.8 ± 10.5 years, 54 (69.2%) were male, mean serum creatinine was 2.49 ± 2.4 mg/dL and mean serum hemoglobin was 7.36 ± 1.7 g/dL. There was a 47.4% rate of readmissions to the same hospital. Transtibial amputation was performed in 59.0%; and transfemoral amputation in 39.7% of the sample. In this sample, 87.2% had a positive culture, predominantly (68.0%) monomicrobial and nosocomial infection of ulcers was observed in 30.8%. The most common bacterial genera were Acinetobacter spp. (24.4%), Morganella spp. (24.4%) and Proteus spp. (23.1%). No bacterial genus was identified as a predictor of death. Creatinine level ≥ 1.3 mg/dL (OR 17.8; IC 2.1-150) and transfemoral amputation (OR 4.5; IC: 1.3-15.7) were associated with death. CONCLUSIONS: Serum creatinine levels ≥ 1.3 mg/dL and transfemoral amputation were risk factors for death.

Persistent fever after pacemaker lead extraction.

The implant indication of cardiac electronic devices continues to expand; therefore, we have observed increasing complications related to their removal. We describe the case of a patient who presented with prolonged bloodstream infection after having undergone removal of a pacemaker. After extensive workup for fever of unknown origin and antibiotic therapy without any improvement, it was possible to demonstrate a foreign body in the right subclavian vein and superior vena cava corresponding to the distal part of the right ventricular lead. Endovascular removal of the foreign body and prolonged antibiotic administration was followed by complete resolution of the clinical picture. We ascribed the difficulty in diagnosing the source of the infection especially to the lack of local manifestations.

Tools and scores for perioperative pulmonary, renal, hepatobiliary, hematological, and surgical site infection risk assessment: an update.

INTRODUCTION: perioperative risk assessment is essential to mitigate surgical complications, which suggests individual and collective interest since the number of surgical procedures in Brazil has been expanding steadily. The aim of this study was to summarize and detail the main calculators, indexes and scores regarding perioperative pulmonary, renal, hepatobiliary, hematological and surgical site infection risks for general non-cardiac surgeries, which are dispersed in the literature. METHOD: a narrative review was performed based on manuscripts in English and Portuguese found in the electronic databases Pubmed/MEDLINE and EMBASE. RESULTS: the review included 11 tools related to the systems covered, for which the application method and its limitations are detailed. CONCLUSION: the non-cardiovascular perioperative risk estimation tools are beneficial when disturbances are identified in the preoperative clinical examination that justify a possible increased risk to the affected system, so the use of these tools provides palpable values to aid in the judgment of surgical risk and benefit as well as it identifies factors amenable to intervention to improve outcomes.

Tools and scores for general and cardiovascular perioperative risk assessment: a narrative review.

The number of surgical procedures in the world is large and in Brazil it has been expressing a growth trend higher than the population growth. In this context, perioperative risk assessment safeguards the optimization of the outcomes sought by the procedures. For this evaluation, anamnesis and physical examination constitute an irreplaceable initial stage which may or may not be followed by complementary exams, interventions for clinical stabilization and application of risk estimation tools. The use of these tools can be very useful in order to obtain objective data for decision making by weighing surgical risk and benefit. Global and cardiovascular risk assessments are of greatest interest in the preoperative period, however information about their methods is scattered in the literature. Some tools such as the American Society of Anesthesiologists Physical Status (ASA PS) and the Revised Cardiac Risk Index (RCRI) are more widely known, while others are less known but can provide valuable information. Here, the main indices, scores and calculators that address general and cardiovascular perioperative risk were detailed.

Diretrizes da Sociedade Brasileira de Angiologia e Cirurgia Vascular para o tratamento da doença cerebrovascular extracraniana / Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Resumo A doença cerebrovascular extracraniana tem sido intensamente investigada em todo o mundo, sendo tema de suma importância para os cirurgiões vasculares. A presente Diretriz foi elaborada pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) em sucessão à Diretriz de 2015. As doenças de etiologia não ateroscleróticas não foram incluídas nesse documento. O objetivo desta Diretriz é congregar as evidências mais robustas nessa área para auxiliar os especialistas no processo decisório do tratamento. Foi utilizada a metodologia AGREE II e o sistema da Sociedade Europeia de Cardiologia para as recomendações e níveis de evidências. As recomendações foram graduadas de I a III, e os níveis de evidência classificados em A, B e C. A presente Diretriz foi dividida em 11 capítulos, que tratam dos vários aspectos da doença cerebrovascular extracraniana: diagnóstico, tratamentos e complicações, de forma atualizada e com as recomendações propostas pela SBACV.

Abstract Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery / Diretrizes sobre acesso vascular para hemodiálise da Sociedade Brasileira de Angiologia e de Cirurgia Vascular

Abstract Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

Resumo A doença renal crônica é um problema de saúde pública global e em seu estágio terminal está associada à necessidade de terapia dialítica. A grande maioria dos pacientes que necessitam realizar a terapia renal substitutiva, a fazem através da hemodiálise. Portanto, o acesso vascular é de extrema importância para a população dialítica, implicando diretamente na qualidade de vida e na morbimortalidade deste grupo de pacientes. Sendo a confecção, gerenciamento e resgate dos acessos vasculares uma das áreas de atuação do cirurgião vascular, é de grande importância a elaboração de uma diretriz que oriente o especialista no manejo mais adequado do acesso vascular para hemodiálise. Assim, o objetivo desta diretriz é apresentar um conjunto de recomendações para guiar as decisões na referenciação, avaliação, escolha, vigilância e gestão das complicações do acesso vascular para hemodiálise.

Hybrid Treatment with Complete Transposition of Supra-Aortic Trunks versus Conventional Surgery for the Treatment of Aortic Arch Aneurysm.

OBJECTIVE: The disease of the aortic arch is traditionally approached by open surgical repair requiring cardiopulmonary bypass and circulatory arrest. This study performed a retrospective analysis comparing outcomes through primary hybrid patients submitted to aortic arch surgery without cardiopulmonary bypass with patients submitted to conventional open surgery. METHODS: 25 patients submitted to the aortic arch surgery were selected in the period 2003-2012 at the Madre Teresa Hospital in the city of Belo Horizonte, Brazil; 13 of these underwent hybrid technique without cardiopulmonary bypass and 12 underwent conventional open surgery. RESULTS: The mortality rate for the hybrid group was 23% and for the conventional surgery group was 17% (P=0.248). The postoperative complication rate was also similar in both groups, with no significant difference. CONCLUSION: Both techniques proved to be similar in mortality and morbidity. However, due to the small sample, more analytical studies with larger samples and long-term follow-up are needed to clarify this issue.

Diabetic foot ulcer carries high amputation and mortality rates, particularly in the presence of advanced age, peripheral artery disease and anemia.

INTRODUCTION: Foot ulcer is also a clinical marker for limb amputation and for death in diabetic patients. The purpose of this study was to determine amputation and mortality rates and its associated factors in patients with diabetic foot ulcerations in a tertiary hospital in Brazil. METHODS: Retrospective medical records from 654 diabetic foot patients were reviewed. The risk factors were determined using the conditional logistic regression model analysis. RESULTS: The mean patient age was 63.1 years (SD 12.20). Peripheral arterial disease was present in 160 patients (24.5%). Major amputations were performed in 135 (21%). The in-hospital mortality rate was 12% and the mortality rate of the amputees was 22.2%. The lowest hemoglobin level, the median value was 9.50g/dL, (4.0-17.0). Anemia was detected in 89.6% of patients submitted to amputation and in 82,1% of those who died. Hemoglobin <11g/dL was the most significant risk factor for major amputation (odds ratio 5.57, p<0.0001). The presence of peripheral arterial disease and old age were also a risk for major amputation (odds ratio 1.84, p=0.007 and 1.02, p=0.028, respectively). Factors associated with increased risk for death were hemoglobin <11g/dL (odds ratio 4.04, p<0.001), major amputation (1.79, p=0.03) and old age (1.05, p<0,001). CONCLUSIONS: Diabetic foot ulcer is associated with high amputation and mortality rates. Old age, peripheral arterial disease and low hemoglobin level are risk factor for major amputation. Old age, major amputation and low hemoglobin level are risk factors for death.

Bacterial genus is a risk factor for major amputation in patients with diabetic foot.

Objective: to evaluate whether bacterial genus is a risk factor for major amputation in patients with diabetic foot and infected ulcer. Methods: we conducted a case-control, observational study of 189 patients with infected ulcers in diabetic feet admitted to the Vascular Surgery Service of the Risoleta Tolentino Neves Hospital, from January 2007 to December 2012. The bacteriological evaluation was performed in deep tissue cultures from the lesions and amputation was considered major when performed above the foot'smiddle tarsus. Results: the patients'mean age was 61.9±12.7 years; 122 (64.6%) were men. The cultures were positive in 86.8%, being monomicrobial in 72% of the cases. In patients with major amputation, Acinetobacter spp. (24.4%), Morganella spp. (24.4%), Proteus spp. (23.1%) and Enterococcus spp. (19.2%) were the most frequent types of bacteria. The most commonly isolated species were Acinetobacter baumannii, Morganella morganii, Pseudomonas aeruginosa and Proteus mirabilis. As predictors of major amputation, we identified the isolation of the generaAcinetobacter spp. and Klebsiella spp., serum creatinine ≥1.3mg/dl and hemoglobin <11g/dl. Conclusion: the bacterial genera Acinetobacter spp. and Klebsiella spp. identified in infected ulcers of patients with diabetic foot were associated with a higher incidence of major amputation.

Objetivo: avaliar se gênero bacteriano é fator de risco para amputação maior em pacientes com pé diabético e úlcera infectada. Método: estudo observacional do tipo caso-controle de 189 pacientes com úlcera infectada em pé diabético admitidos pelo Serviço de Cirurgia Vascular do Hospital Risoleta Tolentino Neves, no período de janeiro de 2007 a dezembro de 2012. A avaliação bacteriológica foi realizada em cultura de tecido profundo das lesões e a amputação foi considerada como maior quando realizada acima do médio tarso do pé. Resultados: a média de idade dos pacientes foi 61,9±12,7 anos e 122 (64,6%) eram homens. As culturas foram positivas em 86,8%, sendo monomicrobianas em 72% dos casos. Nos pacientes com amputação maior, os gêneros de bactérias mais frequentes foram Acinetobacter spp. (24,4%), Morganella spp. (24,4%), Proteus spp. (23,1%) e Enterococcus spp. (19,2%) e as espécies mais isoladas foram Acinetobacter baumannii, Morganella morganii, Pseudomonas aeruginosa e Proteus mirabilis. Identificou-se como fatores preditivos para amputação maior o isolamento dos gêneros Acinetobacter spp. e Klebsiella spp.,e níveis séricos de creatinina ≥1,3mg/dl e de hemoglobina <11g/dl. Conclusão: os gêneros bacterianos Acinetobacter spp. e Klebsiella spp. identificados nas úlceras infectadas dos pacientes com pé diabético associaram-se a maior incidência de amputação maior.

Tools and scores for perioperative pulmonary, renal, hepatobiliary, hematological, and surgical site infection risk assessment: an update / Ferramentas e escores para avaliação de risco perioperatório pulmonar, renal, hepatobiliar, hematológico e de infecção do sítio cirúrgico: uma atualização

ABSTRACT Introduction: perioperative risk assessment is essential to mitigate surgical complications, which suggests individual and collective interest since the number of surgical procedures in Brazil has been expanding steadily. The aim of this study was to summarize and detail the main calculators, indexes and scores regarding perioperative pulmonary, renal, hepatobiliary, hematological and surgical site infection risks for general non-cardiac surgeries, which are dispersed in the literature. Method: a narrative review was performed based on manuscripts in English and Portuguese found in the electronic databases Pubmed/MEDLINE and EMBASE. Results: the review included 11 tools related to the systems covered, for which the application method and its limitations are detailed. Conclusion: the non-cardiovascular perioperative risk estimation tools are beneficial when disturbances are identified in the preoperative clinical examination that justify a possible increased risk to the affected system, so the use of these tools provides palpable values to aid in the judgment of surgical risk and benefit as well as it identifies factors amenable to intervention to improve outcomes.

RESUMO Introdução: a avaliação de risco perioperatório é essencial para mitigação das complicações cirúrgicas, o que aventa interesse individual e coletivo uma vez que o número de procedimentos cirúrgicos no Brasil vem se expandindo de maneira crescente. O objetivo deste estudo foi resumir e detalhar as principais calculadoras, índices e escores dos riscos perioperatórios pulmonar, renal, hepatobiliar, hematológico e de infecção de sítio cirúrgico para cirurgias gerais não cardíacas, os quais encontram-se dispersos na literatura. Método: foi realizada revisão narrativa a partir de manuscritos em inglês e português encontrados nas bases eletrônicas Pubmed/MEDLINE e EMBASE. Resultados: a revisão incluiu 11 ferramentas relativas aos sistemas abordados, para as quais detalha-se o método de aplicação e suas limitações. Conclusão: as ferramentas de estimativa de risco perioperatório não cardiovascular encontram benefício quando se identifica no exame clínico pré-operatório alterações que justifiquem possível risco aumentado ao sistema afetado, assim a utilização destas ferramentas fornece valores palpáveis para auxílio no julgamento de risco e benefício cirúrgico bem como identifica fatores passíveis de intervenção para melhoria dos desfechos.

Tools and scores for general and cardiovascular perioperative risk assessment: a narrative review / Ferramentas e escores para avaliação de risco perioperatório geral e cardiovascular: uma revisão narrativa

ABSTRACT The number of surgical procedures in the world is large and in Brazil it has been expressing a growth trend higher than the population growth. In this context, perioperative risk assessment safeguards the optimization of the outcomes sought by the procedures. For this evaluation, anamnesis and physical examination constitute an irreplaceable initial stage which may or may not be followed by complementary exams, interventions for clinical stabilization and application of risk estimation tools. The use of these tools can be very useful in order to obtain objective data for decision making by weighing surgical risk and benefit. Global and cardiovascular risk assessments are of greatest interest in the preoperative period, however information about their methods is scattered in the literature. Some tools such as the American Society of Anesthesiologists Physical Status (ASA PS) and the Revised Cardiac Risk Index (RCRI) are more widely known, while others are less known but can provide valuable information. Here, the main indices, scores and calculators that address general and cardiovascular perioperative risk were detailed.

RESUMO O número de procedimentos cirúrgicos no mundo é amplo e no Brasil vem expressando tendência de crescimento superior ao crescimento populacional. Nesse contexto, a avaliação de risco perioperatório resguarda a otimização dos desfechos buscados pelos procedimentos. Para a realização dessa avaliação, a anamnese e exame físico constituem etapa inicial insubstituível, a qual pode ou não ser seguida de exames complementares, intervenções para estabilização clínica e aplicação de ferramentas de estimativa de risco. A utilização destas ferramentas pode ser bastante útil a fim de se obter um dado objetivo para a tomada de decisão pesando-se risco e benefício cirúrgico. As avaliações de risco global e cardiovascular são as de maior interesse no pré-operatório, entretanto informações sobre seus métodos encontram-se dispersas na literatura. Algumas ferramentas como o American Society of Anesthesiologists Physical Status (ASA PS) e Índice de Risco Cardíaco Revisado (RCRI) são mais amplamente conhecidos, enquanto outros são menos conhecidos em nosso meio mas podem fornecer informações valiosas. Aqui detalhou-se os principais índices, escores e calculadoras que abordam risco perioperatório geral e cardiovascular.

O volume de fluxo e a velocidade de pico sistólico ao ultrassom vascular com Doppler intraoperatório como preditores de perviedade precoce na fístula arteriovenosa autógena para hemodiálise / Intraoperative vascular Doppler ultrasound blood flow and peak systolic velocity predict early patency in hemodialysis arteriovenous fistula

Resumo Contexto A insuficiência renal crônica é um problema de saúde pública mundial. A hemodiálise é a principal terapia renal substitutiva. As fístulas arteriovenosas (FAV) são uma possível escolha, mas apresentam altas taxas de falência. Objetivos Este estudo tem como objetivo avaliar a relação entre as variáveis hemodinâmicas ao ultrassom vascular com Doppler no intraoperatório e a perviedade precoce da FAV para hemodiálise. Métodos Tratou-se de um estudo prospectivo observacional. Os pacientes consecutivos foram submetidos a FAV com ultrassonografia vascular com Doppler em intraoperatório nos dias 1, 7, 30 e 60. Eles foram divididos em grupos quanto à presença ou não de perviedade primária e secundária, e o volume de fluxo (VF) e a velocidade de pico sistólico (VPS) foram comparados. Foram realizadas curvas receiver operating characteristic (ROC), com definição de valores de VPS e VF com sensibilidade (S) e especificidade (E). Resultados Foram analisados 47 pacientes, os quais preencheram os critérios de inclusão. Os valores de VPS e VF intraoperatório foram maiores nos pacientes com perviedade primária e secundária comparados àqueles com falência. Os seguintes valores apresentaram maiores sensibilidade e especificidade para predizer perviedade primária aos 30 dias: 106 cm/s para VPS venoso, S: 75%, E: 71,4%; e 290,5 mL/min para VF arterial, S: 80,6%, E: 85,7%. Para perviedade secundária aos 30 dias, foram observados: 106 cm/s para VPS arterial, S: 72,7%, E: 100%; e 230 mL/min para VF venoso, com S: 86,4%, E: 100%. Para a perviedade primária no 60º dia, foram observados: 106 cm/s para VPS venoso, S: 74,4%, E: 62,5%; e 290,5 mL/min para VF arterial, S: 80%, E: 75%. Conclusões A velocidade de pico sistólico e o VF ao ultrassom vascular com Doppler intraoperatório são preditores de perviedade precoce na FAV para hemodiálise.

Abstract Background Chronic kidney disease is a major public health problem. Hemodialysis is the most common renal replacement therapy. Arteriovenous fistulas (AVF) are a possible access option, but early failure rates remain high. Objectives to investigate the value of intraoperative vascular Doppler ultrasound for predicting early AVF patency. Methods Prospective observational study. Consecutive patients undergoing AVF were assessed with vascular Doppler ultrasonography intraoperatively and on days 1, 7, 30, and 60. Patients were divided into groups according to presence or absence of primary and secondary patency. Blood flow (BF) and peak systolic velocity (PSV) were compared. ROC curves were plotted and used to define the PSV and BF values that yielded greatest sensitivity (Sens) and specificity (Spec). Results 47 patients met the inclusion criteria and were analyzed. Higher intraoperative PSV and BF values were observed in patients who had primary and secondary patency than in patients with access failure. The values with greatest sensitivity and specificity for predicting 30-day primary patency were 106 cm/s for venous PSV (Sens: 75% and Spec: 71.4%) and 290.5 ml/min for arterial blood flow (Sens: 80.6% and Spec 85.7%). Values for 30-day secondary patency were 106 cm/s for arterial PSV (Sens: 72.7%, Spec: 100%) and 230 ml/min for venous blood flow (Sens: 86.4%, Spec100%). Values for 60-day primary patency were 106 cm/s for venous PSV (Sens: 74.4%, Spec: 62.5%) and 290.5 ml/min for arterial blood flow (Sens: 80%, Spec: 75%). Conclusions Peak systolic velocity and blood flow measured using intraoperative vascular Doppler ultrasound can predict early patency of hemodialysis arteriovenous fistulas.

Treatment of Hostile Proximal Necks During Endovascular Aneurysm Repair.

Endovascular aneurysm repair (EVAR) is a therapy that continues to evolve rapidly as advances in technology are incorporated into new generations of devices and surgical practice. Although EVAR has emerged as a safe and effective treatment for patients with favorable anatomy, treatment of patients with unfavorable anatomy remains controversial and is still an off-label indication for endovascular treatment with some current stent-grafts. The proximal neck of the aneurysm remains the most hostile anatomic barrier to successful endovascular repair with long-term durability. Open surgery for unfavorable necks is still considered the gold standard treatment in contemporary practice, despite the increased mortality and morbidity attributed to suprarenal cross-clamping, particularly in high-risk patients. Evolving technology may overcome the obstacles preventing endovascular treatment of unfavorable proximal neck anatomy; current approaches include purely endovascular as well as hybrid approaches, and generally include strategies that either extend the length of the short neck, move the proximal neck more proximally, or keep the short neck intact. These approaches include the use of debranching techniques, banding, chimneys, fenestrated and branched devices, filling the sac with endobags, endoanchors, and other novel devices. These newer-generation devices appear to have promising short- and midterm results. However, lack of good evidence of efficacy with long-term results for these newer approaches still precludes wide dissemination of endovascular solutions for the hostile proximal neck.